Contraindications

Consent

Technique

Review rationale and imaging

Consent and canulate

Safety checklist and pre-medication. 10% lidocaine spray, 1% lidocaine solution for cords and for spray as you go, remember max intratracheal dose 8mg/kg. Midazolam, less is more +/- fentanyl. Flumazenil comes as 100mcg/ml in in a 5ml ampule, dose is 200 mcg over 15 seconds, then 100 mcg at 1min intervals if required, max 1mg. Naloxone 400 mcg, then 800mcg after a min, repeat if no response then increase to 2mg, 4mg, and rethink diagnosis.

BAL 30ml aliquots into the RML or lingular best for return in diffuse disease, otherwise 30ml aliquots into wherever disease prominent radiographically. exact amount to put in is undetermined.

Endobronchial anatomy

Trachea to carina. Anteriorly cartilage is visible, posteriorly flat membranous wall, arrive at carina and see right main bronchus and left main bronchus

Right main bronchus gives off right upper lobe. Right upper lobe divides into posterior, anterior, and apical branches.

Right main bronchus terminates in a large semilunar orifice which lies anteriorly and is the right middle lobe (it branches into medial and lateral segments). It is separated from the right lower bronchus by a carina. The right lower bronchus gives origin to the posteriorly placed apical basal segment before branching into four basal segments. A smaller semilunar orifice which is the medial basal segment, an anterior basal segment, a lateral basal segment and a posterior basal segment.

Left main bronchus divides at a secondary sharp carina. Left upper bronchus gives off at an angle of about 60 degrees so only its orifice can be seen. Left lower bronchus is almost a direct continuation so its divisions can be seen. Approaching the left upper bronchus the lingular with its uperior and inferior branchesis seen. The upper bronchus divides anterior and apicoposterior segments. Returning to the secondary carina and approaching the left lower lobe the apical lower segment arises first, continuing to the basal segments in a tripartite arrangent of anterior basal segment, lateral basal segment, and posterior basal segment.